Relevance of Uterine Weight for Predicting Surgical Complications in Minimally Invasive Benign Hysterectomy

STUDY OBJECTIVES

To describe the uterine weight threshold for increasing risk of complications after a laparoscopic hysterectomy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

Cross-sectional analysis using the American College of Surgeons NSQIP database from 2016 to 2021.

SETTING

American College of Surgeons NSQIP database.

PATIENTS

Patients undergoing minimally invasive hysterectomy for benign indications (N = 64 289).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Uterine weight was entered in grams and 30-day complications were abstracted from patient charts. In the analytic sample, median uterine weight was 135 grams (interquartile range, 90-215) and 6% of patients (n = 4085) experienced complications. Uterine weight performed very poorly in predicting complications on bivariate analysis (area under the receiver operating characteristics curve, 0.53; 95% confidence interval, 0.53-0.54). On multivariable analysis, a uterine weight cutoff of 163 grams was associated with higher odds of complications (odds ratio, 1.11; 95% confidence interval, 1.03-1.19; p = .003), but this threshold achieved only a 43% sensitivity and 62% specificity for predicting complications.

CONCLUSIONS

Uterine weight alone possessed negligible utility for predicting the risk of perioperative complications in minimally invasive hysterectomy.

Comparison of surgical outcomes between robot-assisted and conventional laparoscopic hysterectomy for large uterus

We compared the effectiveness of conventional total laparoscopic hysterectomy (TLH) against robot-assisted total hysterectomy (RAH) in patients with a large uterus. According to the subtype of minimally invasive hysterectomy performed for benign indications, the patients (n = 843) were grouped as follows: TLH (n = 340) and RAH (n = 503). The median operative time (OT) for TLH was 98 min (47-406 min), and the estimated blood loss (EBL) was 50 mL (5-1800 mL). The median OT for RAH was 90 min (43-251 min), and the EBL was 5 mL (5-850 mL), with a significantly shorter OT and a lower EBL in RAH than in TLH. Uterine weight was categorized into four groups in increments of 250 g. The number of cases in each group was 163 (< 250 g), 116 (250-500 g), 41 (500-750 g), and 20 (≥ 750 g) for TLH, and 308 (< 250 g), 137 (250-500 g), 33 (500-750 g), and 25 (≥ 750 g) for RAH. In patients with a uterus < 250 g, there was no significant difference in OT between TLH and RAH, but in patients with a uterus ≥ 250 g, OT tended to be shorter with RAH, which was also true for a uterus ≥ 750 g. The EBL was significantly lower with RAH compared to TLH, regardless of uterine weight. In patients with a large uterus, the advantages of robotic surgery can be utilized, which may lead to a shorter OT and less EBL.

vNOTES Hysterectomy for Large Uteri: A Retrospective Cohort Study of 114 Patients

STUDY OBJECTIVE

To evaluate the outcome of hysterectomy through vaginal natural orifice transluminal endoscopic surgery (vNOTES) in cases with a large uterus.

DESIGN

A retrospective cohort study.

SETTING

Belgian teaching hospital.

PATIENTS

Women who underwent a vNOTES hysterectomy from March 2015 to March 2020 for benign gynecologic disease with a uterine weight of 280 g or more on pathologic examination (N = 114).

INTERVENTIONS

All women underwent vaginally assisted NOTES hysterectomy. We performed a retrospective analysis of baseline patient characteristics and clinical outcomes.

MEASUREMENTS AND MAIN RESULTS

The mean age was 50 ± 3.5 years. Twenty-two (19%) patients were obese (body mass index ≥30 kg/m²), and 4 (3.5%) were morbidly obese (body mass index ≥40 kg/m²). Thirty-five (31%) patients were nulliparous, and 15 (13%) women had 1 or more cesarean sections in their medical history. Uterine weight varied from 281 g to 3361 g, with a mean weight of 559 ± 425 g. Mean surgical time was 63 ± 34 minutes. Surgical time was positively associated with uterine size. There were 4 complications: 3 bleeding complications in the first 24 hours after surgery and 1 minor late complication. Conversion to laparotomy for specimen extraction was performed in 1 case (conversion rate 0.9%). There were no conversions to laparoscopy. No ureteric, bladder, or intestinal injuries occurred in this case series, and there were neither life-threatening complications nor intensive care unit admissions.

CONCLUSION

The vNOTES technique can offer a safe and effective alternative to laparoscopy or laparotomy in cases with a large to very large uterus, even if the patient has a history of cesarean section, obesity, or nulliparity. In 99% of all women in this study, hysterectomy was successfully performed through vNOTES without conversion. By making use of the advantages of endoscopic surgery, vNOTES might broaden the indications of vaginal hysterectomy. Randomized controlled trials are needed to evaluate whether vaginally assisted NOTES hysterectomy is superior to laparoscopic or abdominal hysterectomy in large uteri cases.

Effects of Huang Bai (Phellodendri Cortex) on bone growth and pubertal development in adolescent female rats

Background

To evaluate the effects of Huang Bai (Phellodendron amurense) on growth and maturation in adolescent female rats.

Methods

Female Sprague-Dawley rats (28 days old; n = 72) were divided into six daily treatment groups: control (distilled water), Huang Bai (100 and 300 mg/kg), recombinant human GH (rhGH; 20 μg/kg), estradiol (1 μg/kg), and triptorelin (100 μg). Body weight, food intake, and vaginal opening were measured daily from postnatal day (PND) 28 to PND 43. Tetracycline (20 mg/kg) was injected on PND 41. After sacrifice on PND 43, the ovaries and uterus were weighed, and the tibias were fixed in 4% paraformaldehyde. Decalcified and dehydrated tibias were sectioned at a thickness of 40 μm, and sectioned tissues were examined with a fluorescence microscope. Insulin-like growth factor (IGF)-1 and bone morphogenetic protein (BMP)-2 were detected using immunohistochemistry.

Results

Relative to controls, body weight was higher in the triptorelin group. Bone growth rate increased in the Huang Bai 100 mg/kg (354.00 ± 31.1 μm/day), rhGH (367.10 ± 27.11 μm/day), and triptorelin (374.50 ± 25.37 μm/day) groups. Expression of IGF-1 and BMP-2 in the hypertrophic zone was higher in all experimental groups. Vaginal opening occurred earlier in the estradiol group (PND 33.58 ± 1.62) than in controls and later in the triptorelin group (PND > 43). Ovarian and uterine weights were lower in the oestradiol and triptorelin groups. However, Huang Bai had nonsignificant effects on vaginal opening and the weights of ovaries and the uterus.

Conclusions

Huang Bai stimulated bone growth by upregulating IGF-1 and BMP-2 in the growth plate. However, it had no effect on pubertal development.

Identifying the Rate-Limiting Step in Total Laparoscopic Hysterectomy in a Training Hospital

STUDY OBJECTIVE

To identify the lengthiest step of total laparoscopic hysterectomy (TLH) in a teaching hospital and to determine which clinical factors affect the duration of this step.

SETTING

The University of Louisville Hospital.

DESIGN

Single institution retrospective case series.

METHODS AND MAIN RESULTS

This is a retrospective chart and video review that included 135 benign, elective TLHs performed at The University of Louisville. TLH was divided into 5 steps: (1) insertion of laparoscopic ports and adhesiolysis to restore normal anatomy; (2) identification of the ureter and resection of adnexal structures to transection of the round ligament; (3) transection of the round ligament to transection of the uterine artery; (4) lateralization of the uterine vessel pedicle to completion of colpotomy; and (5) completion of vaginal cuff closure. The random intercept and slope model was used to identify the lengthiest step of TLH, and the backward elimination procedure was used to evaluate which clinical factors affected this step. Mean ± SD total length of TLH was 81 ± 30 min. The lengthiest step was colpotomy, with a mean duration of 24 ± 13 min. Uterine weight significantly increased the length of time required for colpotomy (p = .001). The primary energy source (ultrasonic scalpel vs monopolar hook) used to perform colpotomy did not influence the length of time (p = .539 vs p = .583). Uterine weight (p < .001) and adhesiolysis (p = .003) significantly increased the total time of TLH.

CONCLUSIONS

At a teaching institution where surgeries are performed by residents and fellows, colpotomy is the lengthiest step of TLH and is influenced by uterine weight. This finding may reflect the training levels of the surgeons performing these cases and the learning curve associated with a challenging surgical skill. Further research should focus on simulation models and/or tools for colpotomy that may result in greater efficiency in the operating room.

Significance of preoperative calculation of uterine weight as an indicator for preserving the uterus in pelvic reconstructive surgery

Recently, increasing evidence has shown that uterus preservation is beneficial for pelvic organ prolapse (POP) patients, both physiologically and psychologically. However, the preoperative indicators for uterus preservation have rarely been examined. The current study was designed to determine the relationship between the preoperative evaluated uterus weight and the operation selection (preserving the uterus or not) in pelvic reconstructive surgery (PRS) using vaginal meshes. First, in a series of 96 patients undergoing hysterectomy, the uterine weight was calculated by preoperative ultrasound measurements, and was then compared with the postoperative actual weight of the uterus. Subsequently, in a series of 65 patients undergone PRS using vaginal meshes and preserving the uterus, the uterine weight was calculated by preoperative ultrasound measurements. Lastly, in a series of 43 patients with a uterine weight > 56.12 g who had undergone PRS using vaginal meshes, the operation success rate in patients with a preserved uterus was compared to patients for whom the uterus was not preserved. The results showed that uterus weight can be evaluated by ultrasound and used as a preoperative indicator for whether the uterus should be preserved or not in PRS when using vaginal meshes. It was indicated that preoperative evaluation of uterine weight is beneficial for surgical planning and guidance.

Does size matter? The effect of uterine weight on robot-assisted total laparoscopic hysterectomy outcomes

The objective of this study was to determine whether uterine weight affects the surgical outcomes of robot-assisted total laparoscopic hysterectomy (RH) procedures. The design of this study is retrospective cohort study. The classification of the study design is level II-2 evidence. The study setting is the Henry Ford Health System's Community Teaching Hospitals. One-hundred and thirty-five patients underwent RH for benign indications at one of two hospitals between January1, 2008, and June 1, 2010. Interventions were scheduled RH without concomitant uro-gynecologic procedures as the intention to treat. Patient demographics, age, height, weight, estimated blood loss (EBL), procedure duration, uterine weight, pathology, length of hospital stay (LOS), and any complications were obtained from a detailed review of electronic medical records. Uterine weight ranged from 47 to 1,290 g (<250 g, n = 87; 250-500 g, n = 28; >500 g, n = 18). Overall, uterine weight was highly correlated with procedure duration (r = .53, P < .001.). Median procedure duration increased from 150 min for the <250 g group, to 205 min for the 250-500 g group, and to 295 min for the >500 g group. Uterine weight was also moderately correlated with EBL (r = .30, P = .0005). Median EBL increased from 50 ml for uteri <250 g to 87.5 ml for the 250-500 g group, and 100 ml for the >500 g group. This correlation did not persist in the assessment of decrease in peri-operative hemoglobin (r = .09, P = .30). Ninety-one women had a LOS of 1 day (67.4%), 31 women had a LOS of 2 days (23%), and 13 women had a LOS of greater than 2 days (9.6%). Uterine weight was not correlated with LOS (r = .14, P = .10) and was not associated with increased major or minor complications (WRS P = .79) re-admission (WRS P = .35), or blood transfusion (n = 3). RH can be performed on patients with large uteri exceeding 500 g without associated adverse outcomes. Although procedure duration is increased, there is no significant effect on EBL and no increase in the occurrence of complications or length of stay.